Addressing social needs in the clinical setting: Description of needs identified in a quality improvement pilot across 3 community hospital service areas

Health care systems are increasingly interested in addressing social needs in the clinical setting for improved health outcomes and lower costs. This retrospective cross-sectional analysis of health records data was a population health pilot project which tested a digital platform to screen and refer patients for social needs across three community hospitals serving Chicago and its South Suburbs. The analysis reports on social needs identified based on the referrals made. Electronic health record data were linked to the referral data to describe patient clinical and demographic characteristics. A total of 2909 patients had at least 1 social need identified. The mean age was 49 years ±21.7 and 65.7% were women. Only 33% of patients had 1 social need identified, indicating that if a social need is identified for patients, they most likely have social needs from other categories as well. Patients of color, specifically African American patients, were 14% more likely to have at least 3 social need categories identified (95% confidence interval of relative risk: 1.02-1.29). Financial stability was the most commonly reported social need (50.7%), followed by food and nutrition (43%). Transportation (22%) and housing (21%) were also commonly reported. This population health initiative reveals that many patients accessing health care have multiple social needs that can be identified at the point of care, and patterns of need-based referral vary by patient clinical and demographic characteristics.